Active Surveillance for Black Men with Low-Risk Prostate Cancer in the United States

161 Background: The National Comprehensive Cancer Network (NCCN) recommends active surveillance as the sole option for men with low-risk prostate cancer (LRPC) and a life expectancy <10 years. We sought to describe the incidence, risk factors, cost, and morbidity related to overtreatment of LRPC within the United States. Methods: We used the Surveillance, Epidemiology and End Results (SEER)-Medicare Program to identify 11,744 men ≥66 years with LRPC diagnosed from 2004-2007. Expected survival was estimated using the 2007 Social Security Life Table and was increased and decreased by 50% in men in the upper and lower quartiles of comorbidity, respectively, as specified by the NCCN. Overtreatment was definitive treatment in men with LRPC and life expectancy <10 years. Costs were the amount paid by Medicare in the year following minus the year prior to diagnosis. Toxicities were defined as relevant Medicare diagnoses or interventions. Results: Of 3001 men with LRPC and a life expectancy <10 years, 2011 (67%) were treated definitively. On multivariable logistic regression, men overtreated for prostate cancer were more likely to be younger (p<.001), white (vs black, OR 1.44, 95% CI 1.03-2.02, p=.03), married (OR 1.30, 95% CI 1.05-1.61, p=.02), urban (trend, OR 1.40, 95% CI 0.98-2.00, p=.06), have higher Elixhauser comorbidity (p<.001), and have a higher clinical stage (T2 vs T1, OR 1.57, 95% CI 1.19-2.07, p=.001) and prostate-specific antigen level (OR 1.02, 95% CI 1.02-1.02, p<.001). Relative to expectant management, the mean added cost per definitive treatment was $15,308. When extrapolated nationally the cumulative net cost of overtreatment in men ≥66 years is $32 million per annum. Long-term urinary, erectile, and bowel toxicity occurred in 59.2% and 50.0%, 47.9% and 19.7%, and 7.1% and 17.8% of prostatectomy and radiation patients, respectively. Conclusions: Overtreatment of prostate cancer is partially driven by sociodemographic factors and occurs in a high percentage of men with LRPC and limited life expectancy, with marked impact on patient quality of life and health care costs. Efforts to enhance appropriate management of LRPC would reduce the harms associated with screening.

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Active surveillance and watchful waiting for low-risk prostate cancer in black patients: A population-based analysis.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.7_suppl.10 ◽

2019 ◽

Vol 37 (7_suppl) ◽

pp. 10-10

Author(s):

Santino Butler ◽

Vinayak Muralidhar ◽

Anthony Victor D'Amico ◽

Paul L. Nguyen ◽

Timothy Rebbeck ◽

...

Keyword(s):

Prostate Cancer ◽

Black Men ◽

Active Surveillance ◽

Conservative Management ◽

Watchful Waiting ◽

Low Risk ◽

Positive Biopsy ◽

Definitive Therapy ◽

Risk Prostate Cancer ◽

Low Risk Prostate Cancer

10 Background: Evidence from clinical trials supports conservative management as an acceptable alternative to definitive therapy for low-risk prostate cancer (LRPC). The optimal approach for Black men, however, remains unclear given trial underrepresentation and concern about racial differences in disease aggressiveness. We therefore sought to determine U.S. conservative management utilization rates for Black men with LRPC. Methods: The Surveillance, Epidemiology, and End Results (SEER) Program Prostate with Active Surveillance/Watchful Waiting (AS/WW) Database queried 50,302 LRPC patients (N = 5218 Black), diagnosed from 2010-2015. Trends in AS/WW utilization over time were determined, stratified by race (Black versus non-Black) and number of positive biopsy cores (≤2 versus ≥3). Results: From 2010 to 2015, AS/WW utilization increased from 12.6% to 36.4% among Black men (Ptrend< 0.001) and from 14.8% to 43.3% among non-Black men (Ptrend< 0.001). AS/WW rates reached 52.0% and 57.3% by 2015 for Black (Ptrend< 0.001) and non-Black (Ptrend< 0.001) men with ≤2 positive biopsy cores, respectively. Rates continually increased for all subgroups except Black men with ≥3 positive biopsy cores, where rates plateaued at 22.9% by 2013. Conclusions: In this report from the largest U.S. population of Black LRPC patients with quality assured AS/WW data, AS/WW rates have nearly tripled for Black men from 2010-2015, suggesting AS/WW is viewed as a safe management option in all races.

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